A nurse is caring for a client who is postoperative following a hemicolectomy. Which of the following is a subjective indication that the client needs PRN pain medication?
The client's heart rate is 110/min.
The client is guarding their abdominal incision.
The client exhibits facial grimacing.
The client reports pain.
The Correct Answer is D
The subjective indication that the client needs PRN (as needed) pain medication is when the client reports pain. Pain is a subjective experience, and it is essential to address the client's self-reported pain level and provide appropriate pain management.
Explanation for the other options:
a) The client's heart rate is 110/min: An increased heart rate can be an objective indication of pain, but it is not a subjective indication. Subjective indications are based on the client's self-report or personal experiences.
b) The client is guarding their abdominal incision: Guarding the abdominal incision may suggest discomfort or pain, but it is an objective indication that can be observed by the nurse. Subjective indications focus on the client's self-report.
c) The client exhibits facial grimacing: Facial grimacing can be an objective indication of pain, but it is not a subjective indication. Again, subjective indications are based on the client's self-report or personal experiences.
In this scenario, the most reliable and appropriate indication for administering PRN pain medication is when the client reports pain, as this acknowledges the client's own perception of their pain level.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
c. The bedroom extension cord is placed under a heavy nightstand.
The nurse should intervene and address the placement of the bedroom extension cord under a heavy nightstand. This poses a safety hazard as it increases the risk of electrical fire or tripping. The nurse shouldmeducate the client about the importance of using proper outlets and avoiding the use of extension cords in general, especially when they are hidden under heavy furniture.
Options a, b, and d do not require immediate intervention by the nurse:
a. The television set turned to a loud volume can be addressed by educating the client about the potential risks of prolonged exposure to loud noises and providing guidance on appropriate volume levels.
b. The presence of low chairs with no armrests in the dining room may not necessarily require immediate intervention unless there are specific safety concerns related to the client's mobility or balance. The nurse may provide general recommendations for safer seating options, especially if the client is at risk of falls or has difficulty getting up from low chairs.
d. The presence of wall-to-wall carpeting in the living room is a common feature in many homes and does not necessarily pose a safety hazard. However, the nurse may discuss general home safety measures, such as keeping the carpet clean and free of tripping hazards, especially for clients with mobility issues.
Correct Answer is B
Explanation
b. Monitor the client for 15 min after meals.
d. Reinforce teaching about healthy eating during meals.
Explanation:
The correct answers are b. Monitor the client for 15 min after meals and d. Reinforce teaching about healthy eating during meals.
When planning care for a client with anorexia nervosa, it is important to focus on interventions that promote safety, nutritional rehabilitation, and psychological support.
Option a, encouraging the client to gain 2.3 kg (5 lb) per week, is not a realistic or healthy goal for weight gain in the context of anorexia nervosa. Rapid weight gain can be physically and psychologically overwhelming for the client and may reinforce disordered eating behaviors. Therefore, it is not an appropriate intervention.
Option c, weighing the client each morning after voiding, may contribute to obsessive monitoring of weight, which is a common feature of anorexia nervosa. Frequent weigh-ins can exacerbate anxiety and fixation on numbers, which are detrimental to the client's recovery. Therefore, it is not an appropriate intervention.
Option b, monitoring the client for 15 minutes after meals, is an important intervention. After meals, individuals with anorexia nervosa may engage in compensatory behaviors such as purging or excessive exercise. Monitoring the client for 15 minutes after meals allows for immediate identification of any concerning behaviors and provides an opportunity for therapeutic intervention, support, and redirection.
Option d, reinforcing teaching about healthy eating during meals, is also an important intervention. Although individuals with anorexia nervosa have distorted thoughts and beliefs related to food, providing education and support during meals can help them develop a healthier relationship with food and challenge their disordered eating behaviors and beliefs.
By recommending the interventions to monitor the client for 15 minutes after meals and reinforce teaching about healthy eating during meals, the nurse addresses the immediate post-meal period, promotes safety, provides support, and assists the client in their recovery journey. These interventions help ensure that the client is receiving appropriate care and support during meal times, which are critical for nutritional rehabilitation and challenging disordered eating behaviors.
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